UofL Making Kentucky Healthier

Delivering Robust Maternal Services

December 1, 2016

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By Jonathan Miller

SPECIAL ADVERTISING REPORT

The University of Louisville strives to improve the lives of the people of Kentucky. Through research, education and clinical care, UofL improves the health of communities across the Commonwealth. Our faculty, staff and students work ceaselessly to seek answers to some of our most difficult health challenges. At the same time, UofL educates the next generation of health care workers to achieve better outcomes, such as improved experiences and vitality for new mothers and their infants, for the youngest heart patients and for dental patients.

Luckily, women expecting a child or getting ready to deliver a baby have many options through the University of Louisville Center for Women & Infants (CWI). The health care providers at CWI offer the most comprehensive set of options in the region.

“We want all women to understand everything available to them as they prepare for delivering their baby,” said Dr. Sean Francis, chair of the department of Obstetrics, Gynecology and Women’s Services at the University of Louisville. “In the past 18 months, we have added a number of services and options that women find enhances their experience of delivering their babies.”

Tub Labor

An inflatable tub is brought into the patient’s room and filled with warm water. The mom-to-be can sit or kneel in any position in the tub to help alleviate pain during labor. The natural buoyancy of the water helps support the mom-to-be, while the warmth soothes and comforts her. Warm water immersion can diminish pain and expedite labor. It can ease tension, lower blood pressure and enhance relaxation during and between contractions. In addition, use of a larger tub increases mobility so that a woman may change position to aid the progress of labor as she becomes tired. When it is time for baby to be born, the mom leaves the tub; this is not a water birth, but use of warm water during labor to help alleviate pain.

Use of Nitrous Oxide Gas During Labor

The mom-to-be may opt to self-administer nitrous oxide gas during labor to alleviate pain. According to the Journal of Midwifery & Women’s Health, “Nitrous oxide labor analgesia is safe for the mother, fetus and neonate and can be made safe for caregivers. It is simple to administer, does not interfere with the release and function of endogenous oxytocin, and has no adverse effects on the normal physiology and progress of labor.” Nitrous oxide does not affect infant alertness during the early bonding period between a mother and her newborn. Women who use nitrous oxide during labor may still be aware of labor pain, but many women find it helps them relax and decreases perception of labor pain. Because it is self-administered, not only can a woman decide how much nitrous oxide to use, but she can also decide if she wants to stop using it and try another method of pain relief.

A range of services including having access to a Certified Nurse Midwife, family-centered Cesarean Sections, Tub Labor and nitrous oxide during delivery are just some of the services that make the UofL Center for Women & Infants one of the most comprehensive centers for women’s health in the region.

2 The Lane Report’s 2016 Health Kentucky lanereport.com

Family-centered Cesarean Section

While still ensuring a sterile environment, the family-centered c-section helps families achieve a gentle, family-centered birth experience. A clear drape is attached to the opaque (blue) drape that is placed over the mom during cesarean delivery. When it is time for the baby to be brought into the world, the opaque drape is peeled away, leaving the clear drape in place. Mother and family are able to view the baby being born and witness its first breath and cry thanks to the large viewing window. The clear-drape cesarean section allows the family to have a more active role in childbirth, even when that birth comes via surgery. Moms who have experienced family-centered c-section say it makes their birthing experience “less like surgery and more like giving birth to my baby.”

Kangaroo Care

The practice of mother holding baby “skin-to-skin” is called Kangaroo Care because it is similar to how a baby joey is carried by the mother kangaroo. Kangaroo Care is begun immediately after birth, providing infant and mother are stable. During this time, the newborn — dressed only in a diaper and hat — rests and recovers from birth on the mother’s chest, skin to skin, so that he or she can smell mom’s scent, hear her heartbeat and voice and be safe and warm. Fathers or the significant other are also encouraged to “Kangaroo” their newborn after the first four hours of life.

Kangaroo Care stresses physical contact to provide a sense of safety for the infant, promote bonding and encourage the natural instinct of breastfeeding. Babies transition better after birth by being close to mother, hearing her heartbeat and voice, and feeling her touch. Babies stay warmer through the “skin-to-skin” contact, may take the first feeding of mother’s milk easier and cry less and sleep more when held skin-to-skin. Babies will not notice pain as much when held skin-to-skin for shots or minor painful procedures. Mothers produce more breast milk when holding babies skin-to-skin, and both mothers and fathers feel more confident caring for their baby if they practice Kangaroo Care. Kangaroo Care also aids in the development of the baby’s brain.

Certified Nurse Midwives

A certified nurse midwife (CNM) is an advanced practice registered nurse in nurse midwifery. CNMs provide care for women during pregnancy and the postpartum period. However, they also provide medical care to women from puberty through menopause, encouraging women to become active, knowledgeable participants in their health care. They prescribe medications, treatments, medical devices, therapeutic and diagnostic measures. CNMs practice in hospitals, private practice medical clinics and birthing centers, and they may also attend at-home births. Some work with academic institutions as professors.

CNMs give expectant families more choices in the birth experience, empowering women to be even more a part of the decision-making process surrounding their labor and delivery. They build a personal relationship with the mother, so she has a more relaxed and less stressed birthing experience. They encourage a natural birth for mothers with low-risk pregnancies. CNMs can order pain medication if it becomes wanted or needed, and perform episiotomies only if necessary. They help minimize labor pain and stress on the baby. CNMs also consult with general obstetricians or maternal-fetal specialists, so patients can rest assured that the full range of obstetrical services are available.

Little Bonnie Gandee likes to be the boss. Even her four-year-old brother, Wyatt, does what the two-year-old says. “She’s a ball of energy,” her mother, Anna, said.

But Bonnie wasn’t in command of life right away. She was diagnosed with a congenital heart problem before she was even born. A routine ultrasound for Anna revealed something might be wrong with her baby’s heart, so she was referred to University of Louisville Physicians for a fetal cardiac scan.

“At first it wasn’t real,” Anna said. “We thought they were just being overly cautious.”

With no specialists near her hometown of Pedro, Ohio, she drove to UofL Physicians’ pediatric cardiology office in Ashland, KY, where a telemedicine conference determined that additional testing and consultation with a fetal cardiology expert was needed.

Anna was then scheduled to see pediatric cardiologist Dr. Brian Holland in Louisville, where he diagnosed Bonnie with complicated congenital heart disease. He told the family she would need several surgeries to try to correct the problem.

“It was at that point we realized this is really happening,” Anna said. “It took my husband a little while to come to terms with it.”

Bonnie’s heart lacked the four chambers a normal, healthy heart has, and hers was essentially functioning with only one of the two main pumping chambers. With the very abnormal chambers in her heart, the blue blood in her heart mixed with the red blood, and the main artery leaving the heart was too narrow to carry the blood to the rest of her body. Soon after birth, she would need immediate and complex bypass surgery, to be followed by two other surgeries later in infancy and young childhood, to correct these abnormalities.

“It was a serious condition. It’s not the same as being born with one of the simpler and more common heart problems,” said Dr. Brad Keller of UofL Physicians, who is Bonnie’s regular pediatric cardiologist.

To help her better understand Bonnie’s condition, Anna said Dr. Holland made sketches for her. “It was a lot to take in, a lot to handle,” she said. “They can tell you everything is going to be fine, but it’s still scary.”

Bonnie was born at Norton Hospital in Louisville and taken across the street to Kosair Children’s Hospital*, where she was under the watchful eye of pediatric specialists and nurses in the neonatal intensive care unit. At just two weeks old, she was scheduled for the first of her three surgeries with UofL Physicians cardiothoracic surgeon Dr. Erle Austin at the Kosair Children’s Hospital Heart Center.

The Heart Center at Kosair Children’s Hospital, working with specialists from UofL Physicians, offers a full range of services for congenital heart defects as well as acquired heart disease, including everything from fetal cardiology to pediatric cardiac catheterization, electrophysiology and open heart surgery, including transplant. It is the only pediatric heart failure and transplant program serving Kentucky and Southern Indiana.

Bonnie’s first surgery was a big one, ensuring she would be stable and healthy enough to undergo other surgeries as she got a bit older.

“When they put the IV in, when it was time to take her back to surgery, that was the worst part,” Anna said. “It was harder than seeing your newborn afterward with all the tubes and medicine and IVs.”

And with more surgeries needed, it wasn’t over for Bonnie or her family.

“At night was my worst fears, afraid that I wouldn’t hear her breathing,” Anna said. “There were a lot of long and restless nights.”

At age six months, Bonnie had a second surgery at the Heart Center to again redirect the blood flow in her body to prepare her heart and lungs for the third and (hopefully) final surgery. When she was almost two, she had the third surgery, which finally allowed the red and blue blood in the body to stay in separate paths and not mix. The surgeries were a success.

“In the 1980s, the chance of survival for a child such as Bonnie would have been 20 to

Bonnie Gandee is one of many children throughout Kentucky who have had their heart conditions repaired by University of Louisville Physicians.

*As of Nov. 10, 2016, the hospital will be named Norton Children’s Hospital.